The Medical Journal of Basrah University

Abstract

Background: Writing the operative notes has vital task in the surgical postgraduate training particularly in plan of postoperative care and dealing with complications following surgery.
Objective: Two hundred and two cases of acute abdomen were examined and revised. The operative notes were written by the postgraduate trainees taking into consideration the guidelines of the Royal College of Surgeons of England and our Teaching Hospital operative note sheet as a reference then combining the two sheets. The time, date and patient's identification was not documented in 23 cases out of 182 and documented but incomplete in 95 cases.
Patients: Nothing was said about anesthesiologist, his assistant and type of anesthesia in 31 cases and some deficient data were mentioned in 93 cases. The position of the patient on the theater table was not written in 11 cases, in the remaining 171 cases the supine position was always used.
The details of incision used in the operative procedure (closure, technique, suture material used) has a role in the morbidity of wound dehiscence and incisional hernia after surgery. In 14 cases, nothing were written about incision and in 164 the data mentioned were not informative.
Results: In 139 cases, biopsy or specimen taken was not mentioned, and specifically in all cases of appendectomies involved in this study no single biopsy or specimen was taken. Closure of the incision in details is fundamental in post-operative sequel. In 169 cases the technique and suture materials used was not mentioned and in 10 cases it was not clear. The result in questionnaire ( 14 trainee) is not that different from the overall cases
Conclusions: Only 10-18% of global surgical teaching programs offer operative notes writing as part of the program. In some studies, there was improvement in quality of the notes writing after teaching the surgical trainees the proper way of writing the operation notes
Keywords: surgery, operative notes written, postgraduate trainees